The global incidence of in-flight medical emergencies: A systematic review and meta-analysis of approximately 1.5 billion airline passengers

Perception, confidence, and willingness to respond to in-flight medical emergencies among medical students: a cross sectional study

BACKGROUND

In-flight medical emergencies (IMEs) are expected to increase as air travel normalized in the post-COVID-19 era. However, few studies have examined health professions students' preparedness to respond to such emergencies. Therefore, this study aimed to investigate medical students' knowledge, confidence, and willingness to assist during an IME in their internship program.

METHODS

This cross-sectional survey utilized an online, self-administered questionnaire-based survey targeted at medical students at two medical colleges in Saudi Arabia. The questionnaire comprised three parts: sociodemographic characteristics, knowledge about aviation medicine (10 items), and confidence (7 items)/willingness (4 items) to assist during an IME. Odds Ratios (OR) and 95% Confidence Intervals (95%CI) were computed to detect potential associations between the knowledge levels and the other independent variables. Responses to confidence and willingness questions were scored on a 5-point Likert scale.

RESULTS

Overall, 61.4% of participants had inadequate knowledge scores for providing care during an IME, and the proportion of participants did not differ between those who had or had not attended life support courses (60.4% vs. 66.7%, p > 0.99). Only frequency of air travel ≥ two times per year was associated with higher odds of adequate knowledge score [OR = 1.89 (95%CI 1.14-3.17), p = 0.02]. In addition, 93.3% of the participants had low, 6.3% had moderate, and 0.8% had high willingness scores, while 86.3% had low, 12.2% had moderate, and 1.5% had high confidence scores. There were no differences in the proportion of participants with low, moderate, and high willingness or confidence scores by attendance in life support courses.

CONCLUSION

Even though over 8 in 10 students in our study had previously attended life support courses, the overwhelming majority lacked the knowledge, confidence, and willingness to assist. Our study underscores the importance of teaching medical students about IMEs and their unique challenges before entering their 7th-year mandatory general internship.

How to Handle In-Flight Death in International Patient Repatriation and Air Ambulance Operations

In-flight cardiac arrest is a rare event that occurs at a rate of approximately 1 event in 3.8 to 4.7 million commercial airline passengers and at a rate of approximately 1 event in 1,500 to 3,000 patients transported by fixed wing international air medical transport. Only 13% to 19% of victims of in-flight cardiac arrest can be successfully resuscitated. The arrival of an aircraft with a deceased patient/passenger on board triggers a country-specific procedure that focuses on public health and medicolegal considerations. In most jurisdictions, these procedures are detailed in the respective national Aeronautical Information Publication, which are commonly based on the International Civil Aviation Organization International Standards and Recommended Practices, Annex 9 to the Convention on International Civil Aviation. Awareness among medical and flight crews on such procedures will support appropriate documentation of the event and enable effective cooperation with the relevant local authorities.

Willingness and self-confidence of healthcare workers in Bahrain in assisting with in-flight emergencies

BACKGROUND

In-flight medical emergency (IFE) impose considerable challenges on healthcare workers (HCWs) because of limited resources, constrained environment, and medico-legal issues. This study assessed HCWs knowledge, willingness, and confidence in addressing in-flight medical emergencies.

MATERIALS AND METHODS

A cross-sectional study was conducted between June and August 2023 among nurses and physicians working in primary healthcare centers and governmental hospitals in Bahrain. Subjects were selected using stratified random sampling; a self-administered online questionnaire of high reliability (Cronbach alpha = 0.914) was used to collect the data. Logistic regression analysis were performed to determine association of knowledge, willingness, and confidence in dealing with in-flight emergencies with various characteristics of HCWs.

RESULTS

The study included 805 HCWs with mean age of 35.5 years (SD=9.2). The findings indicated deficiency in training, with <10% of participants trained on IFE. A considerable proportion of participants exhibited low levels of knowledge (88.3%) and confidence (75.9%) with IFE. Nonetheless, more than half of the participants expressed the willingness to assist in IFE (59.1%). Non-Bahraini healthcare professionals (odds ratio [OR] = 2.901, P < 0.001) had higher knowledge of IFE. Nurses (OR = 1.642, P = 0.047) and participants with longer work experience had higher willingness to assist in IFE. In addition, professionals who were non-Bahraini (OR = 3.249, P < 0.001), working in secondary care (OR = 1.619, 95% confidence interval P = 0.021), had had training on IFE (OR = 2.247, P = 0.004), and had encountered IFE before (OR = 1.974, P = 0.006) had greater self-confidence levels.

CONCLUSION

Considering the low levels of knowledge and confidence healthcare professionals in Bahrain had with regard to IFE, targeted training initiatives and educational programs are necessary to improve HCW's confidence and preparedness to deal with such emergencies.

Worldwide Regulation of the Medical Emergency Kit and First Aid Kit

INTRODUCTION: On-board medical emergencies are increasing. Different geographies have different legislation and requirements for medical emergency kits and first aid kits. A comprehensive review to compare the contents of both kits was conducted, including the International Air Transport Association, European Union Aviation Safety Agency, and Federal Aviation Administration, as well as some from other geographical areas of the globe to cover continents and regions with the highest air traffic, such as Brazil, Kenya, Australia, and Taiwan.METHODS: On June 10, 2023, a search was conducted using standardized medical terms (medical subject headings) within the PubMed® database. The relevant terms identified were "Aircraft" and "Medical Emergencies"; articles published within the last 10 yr were filtered. Subsequently, even articles published before 2013 were consulted if cited by the initial ones. The main regulatory entities' documentation was found using the Google search engine and consulted.CONCLUSIONS: It is impossible to be prepared for every emergency on board. Still, as doctors, we have a moral and ethical obligation to try to improve the outcomes of those emergencies. Getting a standardized report of every on-board emergency is crucial. That would make optimizing the items to include in the emergency and first aid kits easier. There are many similarities among the compared entities, but essential differences have been found. There is room for improvement, especially for pediatric travelers.Oliveira ATB. Worldwide regulation of the medical emergency kit and first aid kit. Aerosp Med Hum Perform. 2024; 95(6):321-326.

Approaches to Medical Emergencies on Commercial Flights

In-flight medical incidents are becoming increasingly critical as passengers with diverse health profiles increase in the skies. In this paper, we reviewed how airlines, aviation authorities, and healthcare professionals respond to such emergencies. The analysis was focused on the strategies developed by the top ten airlines in the world by examining training in basic first aid, collaboration with ground-based medical support, and use of onboard medical equipment. Appropriate training of crew members, availability of adequate medical resources on board airplanes, and improved capabilities of dialogue between a flying plane and medical doctors on the ground will contribute to a positive outcome of the majority of medical issues on board airlines. In this respect, the adoption of advanced telemedicine solutions and the improvement of real-time teleconsultations between aircraft and ground-based professionals can represent the future of aviation medicine, offering more safety and peace of mind to passengers in case of medical problems during a flight.

Considerations for Medical Students' and Residents' Response to an In-Flight Call for Help

INTRODUCTION: High quality cardiopulmonary resuscitation and medical care in an emergency can save lives, especially when resources are limited, as when in flight on a commercial airplane. A medical student or resident may be the most qualified person to offer assistance during an in-flight cardiac arrest; however, he/she may not yet have experience acting as a sole provider on the ground. Moreover, physicians-in-training may feel an ethical obligation to help a fellow passenger in need, but later worry that their help is subject to questions of tort liability action. This commentary will discuss who should volunteer to help in flight, considering the capability, ethics, and legal consequences of medical students and residents providing medical assistance on an airplane. It will also discuss how changes in medical curriculum due to the COVID-19 pandemic may aid medical trainees' ability to help during an in-flight emergency as well as propose further opportunities for training.Edelson J, Ruskin K. Considerations for medical students' and residents' response to an in-flight call for help. Aerosp Med Hum Perform. 2024; 95(1):59-60.

How Common Are Allergic Reactions During Commercial Flights? A Systematic Review and Meta-Analysis

BACKGROUND

Global passenger demand for air travel has increased by over 7% annually since 2006, with a strong recovery following the coronavirus disease 2019 (COVID-19) pandemic. Prior to COVID-19, individuals with food allergies reported significant concern and anxiety over the risk of reactions when travelling by air. However, published data of in-flight medical events (IMEs) due to allergic reactions are limited.

OBJECTIVE

To undertake a systematic review with meta-analysis to estimate the incidence of IMEs due to allergic reactions on commercial flights.

METHODS

We searched MEDLINE, Embase, PsycINFO, and TRANSPORT databases and the Cochrane Register of Controlled Trials for relevant studies reporting IMEs of allergic etiology, published since 1980. Data were extracted in duplicate for meta-analysis, and risk of bias assessed.

STUDY REGISTRATION

PROSPERO CRD42022384341.

RESULTS

Seventeen studies met the inclusion criteria. At meta-analysis, a pooled estimate of 2.2% (95% confidence interval [95% CI] 1.6%-3.1%) of IMEs are coded as being due to allergic reactions. This may be higher in children (3.1%; 95% CI 1.5%-6.6%). The incidence of allergic IMEs at meta-analysis was 0.7 events per million passengers (95% CI 0.4-1.1). Reassuringly, the rate of allergic IMEs has been stable over the past 30 years, despite increasing passenger numbers and food allergy prevalence.

CONCLUSIONS

Allergic reactions coded as IMEs during commercial air travel are uncommon, occurring at an incidence approximately 10 to 100 times lower than that reported for accidental allergic reactions to food occurring in the community. Despite increasing passenger numbers and food allergy prevalence, the rate of allergic IMEs has not changed over the past 3 decades.

The frequency and characteristics of epinephrine use during in-flight allergic events

BACKGROUND

Allergic reactions account for 2% to 4% of medical events in-flight and 5.5% of all medical events in passengers 18 years and under.

OBJECTIVE

To evaluate the incidence of in-flight allergic events including availability, use of epinephrine, and final patient outcome.

METHODS

We conducted a retrospective study of the ground-based medical service (GBMS) database from January 2017 to December 2019 for all allergic events and epinephrine utilization.

RESULTS

A total of 140,579 in-flight medical events (IFMEs) were initially retrieved from the period between January, 2017 and December, 2019, of which 4230 (3.0%) unique cases were identified as allergic events. Epinephrine administration was recommended in 398 passengers by GBMS. Of those, 328 (82.4%) ultimately received at least 1 dose of epinephrine. In multivariate analysis, there was a significant difference in the involvement of volunteers (odds ratio [OR], 3.19; P value < .001; 95% confidence interval [CI], 2.43-4.16), availability of autoinjectors (OR, 2; P value < .001; 95% CI, 1.55-2.58), flight diversion (OR, 11.21; P value < .001; 95% CI, 3.60-34.89), and hospital transport (OR, 6.58; P value < .001; 95% CI, 4.62-9.38) between the 2 groups. Passengers older than 12 years of age were at a higher risk for epinephrine administration. In the secondary analysis of 51 airlines that consistently use GBMS for all IFMEs, the incidence of allergic events was found to be 0.91 cases per million passengers. The incidence of severe in-flight allergic emergencies requiring epinephrine administration was 0.08 cases per million passengers or 12.5 million passengers for 1 event.

CONCLUSION

IFME requiring epinephrine administration is rare with an incidence rate of 1 event in 12.5 million passengers. The risk for epinephrine administration is higher in passengers more than 12 years of age and is associated with significantly higher flight diversion, hospital transport, and involvement of medical volunteers.

Airline Point-of-Care System on Seat Belt for Hybrid Physiological Signal Monitoring

With a focus on disease prevention and health promotion, a reactive and disease-centric healthcare system is revolutionized to a point-of-care model by the application of wearable devices. The convenience and low cost made it possible for long-term monitoring of health problems in long-distance traveling such as flights. While most of the existing health monitoring systems on aircrafts are limited for pilots, point-of-care systems provide choices for passengers to enjoy healthcare at the same level. Here in this paper, an airline point-of-care system containing hybrid electrocardiogram (ECG), breathing, and motion signals detection is proposed. At the same time, we propose the diagnosis of sleep apnea-hypopnea syndrome (SAHS) on flights as an application of this system to satisfy the inevitable demands for sleeping on long-haul flights. The hardware design includes ECG electrodes, flexible piezoelectric belts, and a control box, which enables the system to detect the original data of ECG, breathing, and motion signals. By processing these data with interval extraction-based feature selection method, the signals would be characterized and then provided for the long short-term memory recurrent neural network (LSTM-RNN) to classify the SAHS. Compared with other machine learning methods, our model shows high accuracy up to 84-85% with the lowest overfit problem, which proves its potential application in other related fields.